Furthermore, doctors are hesitant to back substantial financing reforms such as eliminating fee-for-service, but they support reducing unnecessary treatments, Jon Tilburt, MD, MPH, of the Mayo Clinic in Rochester, Minn., and colleagues found.

"More aggressive -- and potentially necessary -- financing changes may need to be phased in with careful monitoring to ensure that they do not infringe on the integrity of individual clinical relationships," the authors wrote in the July 23 issue of the Journal of the American Medical Association.

The researchers mailed surveys to U.S. physicians randomly selected from the American Medical Association's Masterfile to assess physicians' attitudes on addressing healthcare costs. A total of 2,556 of 3,897 replied.

Respondents said trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a "major responsibility" for reducing healthcare costs. However, just 36% reported practicing physicians have the same duty.

Only employers (19%) and physician professional societies (27%) bear less responsibility than individual physicians, the survey found.

"This is a denial of responsibility," Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, both of the University of Pennsylvania in Philadelphia, wrote in an accompanying editorial. "Of course, physicians do not want to be blamed for the country's major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else?"

"Unless physicians want to be marginalized -- unless they are willing to become just another deckhand -- they must accept and affirm that they are responsible for controlling healthcare costs," Emanuel and Steinmetz wrote.

However, despite their other views, 85% of respondents agreed with the statement that "trying to contain costs is the responsibility of every physician."

Also, three-quarters reported they were "very enthusiastic" for promoting the continuity of care. A majority support expanding quality and safety data (51%), promoting head-to-head trials of competing treatments (50%), and limiting access to expensive treatments with little net benefit (51%). Nearly four out of five respondents support the discouraging of interventions that have a small advantage but cost much more.

Doctors were decidedly less supportive of efforts that impact the way they are paid. For example, 7o% weren't supportive of eliminating fee-for-service payment models, 65% opposed bundled payments, and 59% opposed penalties to providers for avoidable hospital readmissions.

"The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system -- steps that may well have the most meaningful effects on controlling costs," Emanuel and Steinmetz wrote.

Tilburt said his findings suggest policymakers may want to start with less dramatic reform efforts such as reducing fraud and abuse and promoting chronic disease care coordination before moving to more extreme physician payment reforms.

"[Physicians] are most enthusiastic about those cost-containing strategies that improve the quality of care, that bring evidence to the bedside, and that are a clear win-win for the doctor, the patient, and the health system," Tilburt told MedPage Today in a video interview. "They get more nervous when their bottom line is at stake."

More than three-quarters of physicians reported being aware of the costs of the tests they ordered, while 78% said they should be devoted to their patients' best interests even if that is expensive.

Other findings included:

43% reported they generally order more tests when they don't know the patient well

70% worried about malpractice liability

55% agreed that following cost-conscious guidelines in practice would be the right thing to do

70% said decision support tools that show costs would be helpful

Tilburt said respondents were slightly older than nonrespondents, but reported no other differences in sex, region, race, or specialty.

"Our results suggest there are subgroups within the profession with distinct identities and professional self-conceptualizations that shape their judgments about addressing healthcare costs," the authors wrote. "In particular, physicians who share a common way of receiving payment, a common type of work context, may share a similar sense of professional obligation. Such relationships are worthy of further investigation."

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